Form Bn0139-0513 - Decline Coverage Acknowledgement Form Page 2
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2NOTICE OF SPECIAL ENROLLMENT
If you are declining enrollment for yourself or your dependents (including your spouse) because of other health insurance
or group health plan coverage, you may be able to enroll yourself and your dependents in this plan if you or your
dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’
other coverage ends (or after the employer stops contributing toward the other coverage).
In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be
able to enroll yourself and your dependents. However, you must request enrollment within 30 days of marriage and 60
days of birth adoption or placement for adoption.
To request special enrollment or obtain more information, contact the Costco Employee Benefit Department at
1-800-284-4882.
BN0139-0513
DECLINE COVERAGE ACKNOWLEDGEMENT FORM
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